Accreditation Field Report: Strong physician support pays off in recent survey
Strong physician support pays off in recent survey
Patient safety, documentation are focus areas
[Editor’s note: This column is a regular feature in Hospital Peer Review profiling a facility that recently has been surveyed by the Joint Commission on Accreditation of Healthcare Organizations. If your facility was surveyed recently, please contact Staci Kusterbeck, Editor, Hospital Peer Review, 280 Nassau Road, Huntington, NY 11743. Telephone: (631) 425-9760. Fax: (631) 271-1603. E-mail: [email protected].]
During a March 2003 Joint Commission survey at the Regional Medical Center of Orangeburg (SC) and Calhoun Counties, strong support from physician leaders paid off, says Indun Whetsell, the facility’s director of quality management.
"We had very strong physician attendance," she reports. "We kept at least one physician with the physician surveyor all the time, and many times had another with the nurse surveyor. Surveyors were very receptive to their attendance."
Physician leaders were well versed in patient safety, quality improvement efforts, and the facility’s peer review committee, Whetsell adds. Medi-cal staff leadership, including the chairman of the executive committee and chief of staff, attended the formal presentation and made themselves available for questions, she says.
Surveyors asked physicians about the National Patient Safety Goals and how the medical staff were involved in performance improvement efforts, Whetsell points out.
"The surveyors wanted to see that they had a global understanding and knew what was going on both in the department and facilitywide." Physicians were able to recount the facility’s success stories, she says.
If you don’t have physicians participating, the surveyors start looking for them and wondering how involved they are, Whetsell explains. "Once it was obvious they were involved, surveyors didn’t dig any deeper."
Here is what surveyors wanted to see at the facility:
• Documentation.
Both the nurse and physician surveyor wanted to see a physician signature for authentication of the history and physical (H&P) on the patient’s preoperative chart, Whetsell explains. "We would have gotten a Type I if our medical records director hadn’t gone on the web site to prove we did not need this."
The medical records director was able to obtain clarification for the time frame required for authentication of documentation, she explains. "Once we presented that, the next morning they backed off. It is a good practice, but it wasn’t a rule."
In addition, the surveyor said that a handwritten H&P on an elective cesarean did not include all the components, Whetsell says. "About 95% of the time, they were dictated, but the nurse happened to take a handwritten chart that time."
As a result, the obstetrics/gynecology department determined that all H&Ps will be dictated on all elective cesareans, she adds.
• Conscious sedation.
"We had made some changes during the year that they liked a lot, but we didn’t have a 12-month track record," Whetsell continues. "But
the surveyors very much acknowledged that we already fixed the problems."
The facility now uses American Society of Anesthesiologists scoring to assess candidates for conscious sedation and has developed a form to ensure consistent practice facilitywide, she explains.
• Same-day surgery callbacks.
The surveyor thought the system used for follow-up calls was inconsistent, says Whetsell.
"They didn’t give us a Type I, but they noted it," she says.
Nurses usually give patients follow-up calls within 24 hours on weekdays; but on weekends, the time frame may be longer, Whetsell explains. Although the facility’s policy intentionally doesn’t specify a time frame, surveyors took issue with this, arguing that there was a difference in the
care patients received after hours, she says.
• Patient safety.
Surveyors went to patients’ rooms and asked them questions, says Whetsell. "There was definitely an increased emphasis on patient safety. They are going to the bedside to make sure you are doing what you are supposed to."
[For more information about the facility’s Joint Commission survey, contact:
• Indun Whetsell, Director, Quality Management, The Regional Medical Center of Orangeburg & Calhoun Counties, 3000 St. Matthews Road, Orangeburg, SC 29118. Telephone: (803) 533-
2688. Fax (803) 539-4011. E-mail: [email protected].]
Editors note: This column is a regular feature in Hospital Peer Review profiling a facility that recently has been surveyed by the Joint Commission on Accreditation of Healthcare Organizations.
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